A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment the patient complains of tingling in her lips and fingers
When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
A) Hypophosphatemia
B) Hypocalcemia
C) Hypermagnesemia
D) Hyperkalemia
Ans: B
Feedback: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it creates slight ischemia of the ulnar nerve. Option A is incorrect; hypophosphatemia creates central nervous dysfunction resulting in seizures and coma. Option C is incorrect; hypermagnesemia creates hypoactive reflexes and somnolence. Option D is incorrect; hyperkalemia creates paresthesias and anxiety.
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To perform scoliosis screening using the Adam forward bend test, what action does the nurse take?
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A pregnant patient receives general anesthesia for a cesarean birth. The nurse is concerned that the patient is developing malignant hyperthermia. What did the nurse assess in this patient? (Select all that apply.)
A) Cyanosis B) Diaphoresis C) Tachycardia D) Cool mottled skin E) Irregular heart rhythm